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Title: Facilitating knowledge exchange between healthcare professionals, organisations and sectors : the impact of boundary spanning processes on quality improvement and integration
Author: Nasir, Laura Calamos
ISNI:       0000 0004 6062 021X
Awarding Body: King's College London
Current Institution: King's College London (University of London)
Date of Award: 2014
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Introduction: The integration of health (and social) care services has been an objective of policy-makers internationally since the 1970s. Patients and practitioners alike want effective and timely care, without having to sacrifice safety or quality. Yet, how system-wide coordination is enabled for a seamless delivery of services remains unclear. Fragmentation continues in healthcare, widely contributing to miscommunication, and inadequate treatment. Background: ‘Boundary spanning’ interventions purport to bridge silos between professional disciplines and provide links across organisations and sectors. Individual boundary spanners often serve as liaisons and conduits for expert knowledge in large and complex systems. Management literature has examined boundary spanning since 1967, and over the last few decades research in the information technology sector has examined how innovative knowledge moves through boundary spanners between organisations. In the health professions, evidence-based practice has been taught widely, and ways to implement effective teamwork in the hospital has been well studied. Yet relatively little is known about how people and groups who function in boundary spanning positions, particularly in complex healthcare systems, effectively share knowledge and collaborate to improve the quality of care and clinical outcomes. PURPOSE The purpose of this study is to describe how boundary spanning activities function in healthcare settings to provide solutions for linking and improving patient care across professions, organisations and sectors. There are two research questions: (1) Does boundary spanning actively lead to knowledge exchange, and if so, what activities facilitate or impede the sharing of information across boundaries? (2) Does knowledge exchange lead to vertical and horizontal integration and if so, how do boundary spanning activities contribute to, or counteract, improvements in patient care, particularly in the effort to provide more seamless services. Design: A longitudinal nested case study design was used to investigate four multidisciplinary cases working to improve healthcare services. Boundary spanning activities were observed in context for 34 months using ethnographic methods. The setting consisted of an newly formed multi-disciplinary project called the ‘Westpark Initiative’ in inner-city London where local stakeholders sought to design their own interventions to improve the integration of local healthcare services. Four multi-disciplinary groups were formed by interested members of the professional community. Each group focused their efforts to integrate services across different boundaries: (1) the Anxiety & Depression in Black and Minority Ethnic Populations case attempted to link primary care and community-based mental health services, (2) the Diabetes case attempted to link primary care and hospital-based specialist care, (3) the Dementia case attempted to link primary and social care, and (4) the Child & Family Services case attempted to link primary care and care in the community and voluntary sector. Methods: Mixed qualitative methods were used with instruments designed specifically for this study. A longitudinal design was used to identify system-wide barriers and enablers to horizontal and vertical service integration from 2009-2012. Data were collected across a broad system of care including: 42 semi-structured staff interviews, 361 hours of participant observations, 36 online serial diaries, two patient and carer focus groups, and historical document analysis. NVivo 9 was used analyse the data to generate themes from the fieldnotes and recorded interview transcripts. Themes from a boundary spanning literature review, including noted barriers and enablers of vertical and horizontal integration were identified. A management theory that describes knowledge exchange in complex organisations was selected as an additional analytical framework to add further depth to the investigation. Nonaka’s SECI (Socialisation → Externalisation → Combination → Internalisation) model was used to explore how tacit and explicit knowledge were exchanged, how innovative solutions surfaced, and how patient outcomes were defined by each of the cases, and in combined dimensions. The SECI model has never previously been applied to the healthcare setting. Results: Facilitated learning events provided empowering professional socialisation for participants of all four cases, which helped tacit knowledge cross individual, organisational, and sectoral boundaries. Missed opportunities for sharing expertise was observed in all contexts, noting that mentored group meetings, flexible meeting agendas, and appropriate goal setting was crucial to move tacit knowledge across boundaries and surface integrating solutions through combination and dialogue. Socialisation and charismatic leadership was not enough to affect integration. Barriers to exchanging both tacit and explicit knowledge included practice managers functioning as gatekeepers, supervisors’ adaptive style, competing accountability concerns, and political (and financial) imbalances. Explicit knowledge exchange through construction of products and introduction of systemised solutions was noted in the Anxiety & Depression, Diabetes, and Child & Family Services cases, particularly where enabled by external resources (including funding). The Anxiety & Depression case had a well-defined goal (from national guidelines) of increasing referrals to talk therapy, which was measurable, and achieved. The Diabetes case achieved vertical integration with the opening of community-based clinics staffed by Diabetic Specialist Nurses. These two cases also demonstrated movement of explicit knowledge to internalised tacit knowledge, which routinised integrating solutions for more chance of lasting success. Only limited knowledge exchange was accomplished through informational sessions and leaflets by the two remaining cases, as the Dementia and Child & Family Services case struggled to make any lasting links between general practice and secondary care. Scalability was a concern, particularly where redundancies and reorganisations were experienced in the local context, which impeded horizontal integration efforts by these cases. All four cases struggled to define meaningful measures to link their integration goals with patient outcomes, and all experienced top-down pressures to use quantitative national measures, despite being deemed too insensitive to judge impact of integration on patient care. The Anxiety & Depression case had the most ability to embed reflection in their daily practice, more ability to surface innovative local solutions, and the benefit of funding for routinised team-building activities. Persistent mentoring and routine learning sets about embedding data collection in practice was a necessary though time-consuming factor in leading quality improvement efforts, especially by those groups attempting new local methods of integration. Conclusion: Boundary spanning activity can increase opportunities for knowledge exchange, which in turn can lead to integration – but there are important variations in context, which enable the kind of local innovations, which contribute to lasting connections between professions, organisations, and sectors. Knowledge exchange did enable integrating solutions, especially when moving from tacit to explicit, though socialisation was not enough. Horizontal integration was achieved with link workers and frequent outreach to the local population and practitioners. Vertical integration was achieved through political negotiations and repeated accountability-sharing discussions. Locally responsive cross-boundary teams and adaptable management styles appear to play a role in the development of innovative solutions. Systemising problem-solving processes and embedding data collection were also important aspects of integration efforts. Reflective practices, which included learning about how to embed data collection, appear to play a role in longitudinal success. Future research will need to clarify methods for measuring the impact of boundary spanning activities through a range of tools that describe, examine, and measure the outcomes of multi-disciplinary, multi-level interventions that span complex interfaces in healthcare. There remains a distinct need to further the empiric study of how integration contributes directly to improving patient outcomes and the quality of care – and how to extend this learning to teach future healthcare practitioners to span boundaries, recognise, and implement innovative solutions, and provide truly continuous services in all settings.
Supervisor: Robert, Glenn Brian ; Norman, Ian James Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available